Diagnostic Procedures Template

1
Diagnostic Procedures Template

• NAME OF PROCEDURE
• Typically used by
• Overview
• History
• Commonly associated terms and concepts
• Mode of use
• Physiological rationale
• Evidence
• Discussion and conclusions
• References

2
Leg checking (I)

• Typically used by
• Upper Cervical techniques
• Diversified
• Pierce-Stillwagon/Thompson
• Sacro-Occipital Technique
• Activator Methods
• Directional Non-Force Technique
• Etc.
• Overview
• Functional vs. structural LLI
• LLI as direct cause of back and other somatic
  pain
• LLI as diagnositic indicator
• Pelvis
• Upper cervical
• LLI as outcome measure
• History
• Van Rumpt (DNFT) described the reactive leg
  early in history of chiropractic

3
Leg checking (II)

• Commonly associated terms and concepts
• Leg length inequality (anisomelia, leg length
  discrepancy, etc.) Asymmetry in distal foot
  positions, due to anatomic or functional factors
• Leg checking a procedure, usually but not always
  manual and visual, for assessing LLI
• Anatomical short leg (or structural short leg) A
  leg which is demonstrably shorter than the other
  leg, due to fracture, deformity, or uneven growth
  rates
• Functional short leg (or physiological short leg,
  apparent short leg, etc.)A leg which is actually
  even in length with the other leg, but which
  appears shorter due to a postural imbalance that
  draws up the hip in the non-weight bearing
  position
• Supine leg check Leg checking procedure commonly
  employed by upper cervical practitioners, thought
  to identify atlas subluxation
• Prone leg check Leg checking procedure commonly
  employed by full spine practitioners, usually
  thought to identify pelvic torsion, with
  posterior innominate rotation on the short leg
  side.
• Derifield leg check A prone leg checking
  protocol involving 2 primary components (a)
  assessment of relative leg lengths with the knees
  extended compared to knees flexed to 900.
  identifying pelvic syndrome and (b) assessment
  of change in relative leg lengths as the head is
  turned in either direction, identifying cervical
  syndrome

4
Leg Checking (III)

• Mode of use
• Standardized mounting procedure
• Removing unwanted degrees of freedom
• Supine, prone
• Derifield variation
• Instrumented leg checking
• Chiroslide
• Anatomer
• Modified surgical boots
• Tape measure methods
• Scanogram
• Measurement screen

5
Friction-reduced table
6
Chiroslide
7
Anatometer
8
Whats wrongwith this picture?
9
Leg checking (IV)

• Physiological rationales

10
Allis (Galeazzi) test
Knee higher ? long tibia Knee distal ? long femur
11
Allis validity study done at Palmer West
12
Leg checks Evidence (I)

• Rhudy TR, Burk JM. Inter-examiner reliability of
  functional leg-length assessment. American
  Journal of Chiropractic Medicine 19903(2)63-66.
• Mannello DM. Leg length inequality. J
  Manipulative Physiol Ther 199215(9)576-590.
• Falltrick DR, Pierson DS. Precise measurement of
  functional leg length inequality and changes due
  to cervical spine rotation in pain-free subjects.
  J Manipulative Physiol Ther 198912(5)369-373.

13
Leg Checks Evidence (II)

• Reliable to some extent
• Nguyen, 1999
• Bishop, 1995
• Hinson, 1998 (supine)
• Validity poorly studied, however
• Cooperstein R, Morschhauser E, Lisi A, Nick TG.
  Validity of compressive leg checking in measuring
  artificial leg-length inequality. JMPT
  200326(9)557-66.
• Cooperstein R, Morschhauser E, Lisi A.
  Cross-sectional validity of compressive leg
  checking in measuring artificially created leg
  length inequality. Journal of Chiropractic
  Medicine in press.

14
Discussion and conclusions LLI

• Friberg on anatomic LLI Friberg O. Leg length
  inequality and low back pain. Clinical
  Biomechanics 19872211-219.
• Anatomic vs. structural LLI still not
  accomplished
• Reliability of leg checks better established than
  validity

15
Palpation, static and motion (I)

• NAME OF PROCEDURE
• Typically used by
• all chiropractors
• Static
• Motion MPI
• Overview
• History

16
Motion Palpation Institute
17
Palpation (I)

• Commonly associated terms and concepts
• Misalignment
• Range of motion, active and passive
• Static and motion palpation
• Paraphysiological joint space
• Restriction
• Accessory joint movements
• Hard and soft end-feel
• Joint play

18
Palpation (II)

• Mode of use
• Intersegmental motion
• Unisegmental motion
• Physiological rationale (Gillet)
• three stages of joint fixation
• muscular hypertonicity
• ligamentous shortening
• articular adhesions
• Facilitation model
• Muscle hypertonus
• Hyperalgesia
• Autonomic disturbance

19
Palpation (III)

• Evidence
• Troyanovich SJ, Harrison DD. Motion Palpation
  It's time to accept the evidence. JMPT
  199821(8)568-571.
• Hestbaek L, Leboeuf-Yde C. Are chiropractic tests
  for the lumbo-pelvic spine reliable and valid? A
  systematic critical literature review. JMPT
  200023(4)258-75.
• Haas M, Groupp E, Panzer D, Partna L, Lumsden S,
  Aickin M. Efficacy of cervical endplay assessment
  as an indicator for spinal manipulation. Spine
  200328(11)1091-6 discussion 1096.
• Discussion and conclusions
• Hard to research
• Qualitative factors
• How to choose studied, plausible, not reliable
  vs, unstudied but weird

20
Manual muscle testing

• NAME OF PROCEDURE
• Typically used by
• Overview
• History
• Commonly associated terms and concepts
• Mode of use
• Physiological rationale
• Evidence
• Discussion and conclusions
• References

21
Some types of manual muscle testing
Self-testing (!)
Using a challenge
22
Manual muscle testing improves w/experience
Caruso and Leisman investigated the
force/displacement characteristics of manual
muscle testing, finding that a relatively steep
slope meaning that the distance through which
the tested limb moves as a function of force
application is large predicts with 98 accuracy
that an experienced manual muscle tester would
find a weak muscle. A less experienced muscle
tester would get it right, under the assumption
that the force/displacement curve is definitive,
only 64 of the time. The authors conclude The
experiment lays the groundwork for studies of the
objectivity of muscle-strength assessment in
applied kinesiology.
Caruso W, Leisman G. A force/displacement
analysis of muscle testing. Percept Mot Skills
200091(2)683-92. Caruso W, Leisman G. The
clinical utility of force/displacement analysis
of muscle testing in applied kinesiology. Int J
Neurosci 2001106(3-4)147-57.
23
Line marking A case in point
24
Line marking and positioning can be reliable
X-ray line drawing analysis for spinal
displacement was found to have high reliability
with a majority of ICCs in the .8-.9 range. The
reliability for determining X-ray pathology was
found to be only fair to good by both medical
doctors and chiropractors and by both
chiropractic and medical radiologists, with a
majority of ICCs in the range .40-.75. (Harrison
DE, Harrison DD, Troyanovich SJ. Reliability of
spinal displacement analysis of plain X-rays a
review of commonly accepted facts and fallacies
with implications for chiropractic education and
technique JMPT 199821(4)252-66.) Repeat
anteroposterior radiography of the human pelvis
was performed in vivo. Comparative examinations
were performed after 1 hr in one subject pool. A
second sample underwent repeat examination after
a mean of 18 days. . . . A subject can be
reliably positioned for repeat anteroposterior
pelvic radiography for both 1 hr and 18-day
intervals. the pelvis are scrutinized.
(Plaugher G, Hendricks AH, Doble RW, Jr., Bachman
TR, Araghi HJ, Hoffart VM. The reliability of
patient positioning for evaluating static
radiologic parameters of the human pelvis. JMPT
199316(8)517-522.)
25
Thermograph, infrared, Titron C-3000
Advertising or clinically valuable? Whether you
are opening a new clinic, building a patient base
or maintaining the patients you already have, the
TyTron C-3000 is the best investment you can
make. The TyTron C-3000 effectively educates your
patients on their chiropractic needs.
26
Triple response and dual probe thermography
Neurocalometer (above), nervoscope (below)
27
Is Nervoscope reliable?
C4-T2 Kappa.03
as instrument was used in repeat sequence,
findings became more stable
T4-T8 Kappa..57 (1st observation) Kappa.65
(2nd observation)
L2-L5 Kappa could not be computed, too many
positives for each examiner
It must be noted that this type of concordance
is regional and not segmentally specific. (!)
Plaugher G, Lopes MA, Melch PE, Cremata EE. The
inter- and intraexaminer reliability of a
paraspinal skin temperature differential
instrument. Journal of Manipulative and
Physiological Therapeutics 199114(6)361-367.
28
Field study in mis-citation

• One study of the Gonstead system by Plaugher et
  al showed fair to good interexaminer reliability
  for the Nervoscope . . . as it is used to
  determine segmental side-to-side temperature
  differences (breaks)

29
Tissue compliance meter
30
ECS not good
31
How hard things are . . .(Lucas Cooperstein,
2004)